Length of Hospital Stay as a Performance Metric-Is That a Fair Assessment?

In a healthcare sector that is constantly evolving, quality improvement has become one of the main areas of focus. Often tough to measure, the three pillars of quality improvement—structure, process, and outcome—provide the cornerstone on which advances in quality can be achieved. Length of stay (LOS) is one such often talked about outcome metric. It is desirable to have shorter lengths of stay since a longer LOS would generally indicate less efficient care and possibly higher complication rate and would in turn be less economical to the healthcare system. However, the relationship between the best possible care and LOS is seldom straightforward. This current issue of Seminars in Cardiothoracic and Vascular Anesthesia (SCVA) delves a bit into the strategies to predict and reduce hospital LOS. Two original research articles discuss predictive variables and therapeutic interventions to reduce hospital LOS, respectively. This is followed by two review articles to analyze the prevention and management of neurocognitive disorders after cardiac surgery and the management of perioperative diastolic dysfunction. A comprehensive review discusses biventricular repair from the perspective of the congenital cardiac anesthesiologist. The issue is rounded off by two interesting case reports that discuss challenging perioperative hemodynamic situations in thoracic surgery. In our firstOriginal Research article, Wang and colleagues analyzed the role of perioperative serum albumin and the albumin–bilirubin (ALBI) grade in predicting post-liver transplant LOS. In a single-institution study, they looked at 663 liver transplant recipients and concluded that a higher pre-operative serum albumin level was associated with a shorter hospital LOS. They also concluded that a lower ALBI grade, which is possibly a marker of greater hepatic synthetic activity, was associated with shorter hospital and intensive care unit (ICU) LOS in patients with a low Model for End Stage Liver Disease–sodium (MELD-Na) score. However, there was no difference in operative mortality across the ALBI grades. Higher MELD-Na scores are known to be associated with worse postoperative outcomes and would alert clinicians to the possibility of longer hospital and ICU LOS. The ability to risk stratify patients that are otherwise “low risk”with lowerMELD-Na scores based on ALBI grade makes this paper pertinent and may pave the way for future trials to investigate the role of ALBI in this subset of patients. Minimally invasive valve surgery has continued to evolve and can now be performed safely with shorter ICU and hospital LOS, while keeping the quality of the operation similar to that performed through a full sternotomy. Postoperative pain has been one of the barriers to a faster recovery and earlier discharge following minimally invasive valve surgery, and this may be because of extensive rib retraction and division of intercostal muscles associated with the surgical procedure. In the second Original Research article, Cheruku et al studied the outcomes of thoracic interfascial plane blocks after mini-thoracotomy for valve surgery. In a single center, single surgeon retrospective study, 400 consecutive patients who underwent minimally invasive mitral or aortic surgery, and were extubated within 2 hours of the procedure, were included. Forty-eight percent (193 patients) received an interfascial block, while 52% (207 patients) did not. They concluded that patients who received a thoracic interfascial block had a modest reduction in maximum visual analogue scale (VAS) pain score when compared to those who did not (mean VAS score 7.4 ± 2.5 vs 7.9 ± 2.2, P = .02). This did not translate to a significant reduction in opioid